Disparities Grow as Smoking Rates Rise Again

Life expectancy is declining as cigarette sales increased for the first time in 20 years

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In 2020, for the first time in two decades, cigarette sales increased. The state of cigarette smoking became so bad that the US Surgeon General released a report for the first time in two decades about the negative health effects of smoking. 

28 million Americans smoke cigarettes, killing 480,000 people every year. An additional 41,000 die each year from secondhand smoke, making smoking the #3 cause of death in America.

Smoking is also far more deadly in America. The death rate from smoking in the US is nearly double that of comparable wealthy countries, largely due to the country’s fractured healthcare system and the at-risk populations that are targeted by smoking ads.

Smoking killed more people than COVID did in 2021, the disease’s deadliest year on record.

Since the Surgeon General’s first report on smoking in 1964, more than 20 million premature deaths can be attributed to cigarette smoking.

People who smoke generally die 10 years earlier than their peers who do not smoke, even when accounting for race, income, and regional differences. 

E-cigarettes and vaping usage have had a meteoric rise in the US, and with that comes additional negative health effects. Most importantly, these negative health effects are concentrated among disadvantaged youth. 

Low-income Americans smoke at far higher rates

18.6% of low-income Americans smoke cigarettes compared to 6.7% of high-income Americans. The CDC explains why this is the case, “Neighborhoods where people have lower incomes tend to have more stores selling and advertising commercial tobacco. In neighborhoods with a lower socioeconomic status, there is a significantly higher weekly unit sales of tobacco products per tobacco retail store.” Not exactly a causal explanation, but oh well. Tobacco and vaping stores tend to move to low-income areas, market much more heavily to these communities, and get these populations addicted to cigarettes at much higher rates. 

One study looking across 30 US cities found that there are 5x more tobacco retailers in low-income neighborhoods than in high-income neighborhoods. This also holds true for e-Cigarette and vaping stores. 

Another study found that Black communities were 70% more likely to have smoking billboards or advertisements that were smoking related as compared to surrounding White neighborhoods.  Overall this amounted to 2.6x as many tobacco advertisements per person in Black areas. If communities are being bombarded with smoking ads at such high rates, it is no surprise that they start smoking even if they know of the negative health impacts.

Many of you are probably thinking, Wait I thought it wasn’t legal to advertise for smoking or cigarettes? This isn’t entirely true. In 1971, the Federal Trade Commission (FTC) made it illegal to advertise any cigarette products on radio, television, or other media regulated by the Federal Communications Commission. However, the FDA still permits some advertising of cigarette products in billboards and on-street advertisements like the one below; these ads only need to have warnings in 12-point font written in legible Helvetica bold or Arial bold. 

Several states have implemented their own bans on advertising, which is a huge reason why we see such differences in smoking outcomes in states. The states that have the longest histories of tobacco production (Georgia, Tennessee, North Carolina, and Virginia) are the least likely ones to implement advertising bans. 

In 2019, tobacco companies spent $25 million every day according to the CDC to market their products to US consumers. Most of this advertising happens in stores like 7-Eleven and gas stations, but a huge portion also comes in the form of discounts for retailers and wholesalers. 

The average American smoker consumes 1,061 cigarettes per year, which is roughly in line with the global average. However, the death rate for Americans who smoke is 50-100% higher than in comparable wealthy countries. This is in part due to the more onerous and fractured healthcare system that the U.S. has, especially for lower income Americans who are much more likely to be smokers. Low-income Americans are also much. Low-income Americans are also much more likely to suffer from cancer as American Inequality has previously discussed. 

Holly Hagle explains that her dad would have lived another 10 years if he hadn’t smoked. He started smoking when he was 12 - many more people start smoking at such an early age than we realize. He tried quitting multiple times and she explained that at one point he was able to quit for more than a year. But Holly knows that nicotine is one of the hardest addictions to recover from - she works at the Institute for Research, Education, and Training in Addictions. She made the point that has really stuck with me: “Even though we are in an epidemic of opioid addiction and especially opioid overdose, tobacco is still the #1 substance responsible for deaths worldwide”

Cigarette smoking alone has cost the US $96 billion in direct medical expenses and $97 billion in lost productivity per year, or an average of $4,260 per adult smoker. 

The geography of smoking

South Dakota is home to 3 of the 5 counties with the highest percent of cigarette smokers. We’ve written about one of those counties, Oglala Lakota County, several times before as it has the lowest life expectancy of any county in the US (residents die at 67 on average), and median income is $30,347. Meanwhile, Utah is home to 6 of the 10 counties with the lowest percent of cigarette smokers. American Inequality has covered several of these counties before. For example, Summit County has the highest life expectancy of any county in the US (residents die at 87 on average), and median income is 2.5x higher than in Oglala. 

Cigarette smoking is 50% higher than in the following 12 states compared to the rest of the nation: Alabama, Arkansas, Indiana, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Ohio, Oklahoma, Tennessee and West Virginia. An average smoker in these 12 states goes through about 53 packs in one year, compared with an average of 29 packs in the rest of the US. Life expectancy is 3 years lower in these states compared to the national average. 

In 1998, California became the first state to implement a smoke free law prohibiting smoking in all indoor areas of bars and restaurants, as well as in most indoor workplaces. As we can see from the map above, California now has one of the lowest percent of adults smoking in the country. 

E-Cigarettes and Vaping

In April 2023, JUUL reached a $462 million settlement with 47 states and territories, and 5,000 individuals and local governments for failing to warn young users that the high levels of nicotine in their e-cigarettes would prove addictive. Not only did the company hide this information about addiction, they also handed out countless free products for years beginning in 2015 (often at high schools) to get young consumers onboard. JUUL disclosed in the lawsuit that they shipped e-cigarettes to consumers who gave student email addresses. 

JUUL’s very first ads ran on Cartoon Network, Nickelodeon, and in Seventeen Magazine. 

In August 2023 JUUL announced that it would be laying off 30% of its staff. 

99% of e-cigarettes sold contain nicotine, according to the CDC, making them far more addictive than non-nicotine-containing e-cigarettes. This is incredibly challenging since the market for vapes and e-cigarettes tends to target teenagers. 

From 2011 to 2019, e-cigarette usage increased 1,065% for middle schoolers and 1,773% for high schoolers according to the American Lung Association. In 2019, close to 2.9 million children started using e-cigarettes, or more than 7,900 per day. This was an increase from more than 2.2 million in 2018 and close to 2.1 million in 2017. Researchers from Johns Hopkins University have found that people who vape, particularly young adults, are more likely to become cigarette smokers later in life. Nevertheless, studies have pointed out that e-cigarettes are a helpful alternative to smoking cigarettes and that they can actually help people stop smoking altogether. 

In the meantime, e-cigarettes cost the U.S. $15 billion in direct medical expenses every year. 

E-cigarette usage has increased dramatically for high schoolers - Source: Baker Institute

Interestingly enough, surveys have found that Black and Hispanic communities tend to believe that e-cigarettes are more harmful, resulting in continued higher rates of cigarette smoking in these communities.  

The Path Forward

We can use data to identify solutions that retailers, state/local governments, and parents can take to address the tremendous rise of smoking in the US. We can focus on cost, controls, and children to makes sure we are addressing this huge factor in influencing life expectancy.  

• 💸 Costs: Increase taxes on harmful products - Countries that increased taxes on tobacco saw tremendous declines in consumption. In Qatar for example, a 3.3% increase in taxes saw a 22.9% decrease in consumption. Every 10% increase in the price of cigarettes reduces youth consumption by 7% and another study found that a $2 increase per pack could reduce consumption by 40%. These are often referred to as ‘sin taxes’ for bad products that we want to get rid of, but I think we can reframe these as ‘life saving taxes’ that allow communities to thrive and avoid dying too early. 

• 🛑 Controls: Stop advertising tobacco products - There are such vested interests and so much money that pours into smoking advertisements. The US has been ranked as being most similar to Somalia, Venezuela, Sierra Leone, and the Congo in terms of bans on cigarettes. E-cigarettes and vaping don’t seem to have the same controls yet in place to stop their advertising. In a 16-year study of 20 countries that instituted full bans on advertising tobacco products, cigarette consumption declined by 2-10%. In New Zealand, an ad ban was associated with an 11.3% decrease in smoking during a 6-month period. Researchers have also found that banning these advertisements is one of the best investments in reducing the rate of smoking while also helping eliminate some of the racial and socioeconomic gaps in consumption. 

• 👶 Children: Reduce density of smoking retailers near schools - 77% of public schools are within a 10-minute walk of at least one outlet selling tobacco. And for every 1 McDonalds, there are 26 tobacco retailers. The number of these stores in an area increases 8% for every 10% increase in Hispanic students attending a school. In 2010, Santa Clara County in California passed an ordinance banning tobacco retailers from opening any new stores within 1,000 feet of a school. In 2013, Chicago became the first place to pass an ordinance banning the sale of all flavored products, including menthol, within 500 feet of schools. In 2016, Philadelphia implemented retailer regulations that included a ban on any new retailers located within 500 feet of schools. 3 years after Philadelphia implemented this study, 20% of retailers in low-income areas closed leading to a decrease in youth smoking. 

Most people know that smoking is bad for one’s health, but larger forces can make it difficult for certain communities to overcome this deep rooted knowledge. If we want to address the #3 killer in America, we need to take steps to recognize that there is still a long way to go to make progress. If we don’t act soon, Black communities, children, and low-income communities will continue to suffer. This path-forward will help us close the 10-year gap in life expectancy between people who smoke and those who do not.